One of the most common and costly forms of fraud in the United States is Medicare fraud. It costs the government billions of dollars each year and exploits a system that is designed to help those who need it most.
When people think of Medicare fraud, they might be tempted to think that it is Medicare patients who are perpetrating fraud against the system. In reality, the types of fraud that really add up to incredible amounts of money lost to taxpayers is not due to the actions of beneficiaries, but of healthcare providers and medical professionals. It’s for this reason that workers in healthcare facilities can be such a key component in identifying and reporting Medicare fraud.
There are many different types of Medicare fraud. Sometimes it involves individuals who found ways to bend the rules to get more payment than needed. Sometimes it involves institutional corruption, with complex systems set up to syphon of billions of dollars from the system.
For those who work in facilities that bill or receive payments from the government for services covered by Medicare, it is beneficial to know the different forms of Medicare fraud so that you can identify it when it happens. Not only does the government save vast sums of money based on the information provided by people who report fraud, they also pay rewards to these whistleblowers as an incentive for workers to step forward.
Why Medicare Fraud is So Common
Medicare has been an “easy target” for so many perpetrators of fraud because it relies on the honest report and billing of services rendered that are covered by the Medicare Trust Fund. As Medicare expands to cover more citizens, it is also more vulnerable to exploitation. Through the years, Medicare fraudsters have developed a seemingly endless number of ways to gouge the system.
Common Forms of Medicare Fraud
Medicare fraud typically involves billing for services that have never actually occurred, were unnecessary or which actually cost much less than the amount billed. For example, one method of overbilling Medicare is called Upcoding, in which a billing code is used to inflate the amount of money owed for a given procedure.
Another practice that falls under the Medicare fraud category is the prohibited referral of services that result in a kickback to the party that made the referral. In most cases, referrals of certain services that result in payments or kickbacks are violations of the Anti-Kickback Statute or the Physician Self-Referral Law.
Examples of Medicare Fraud
In July of 2016, the Justice Department released the details of Medicare fraud that amounted to over $1 billion of improper billing against Medicaid and Medicare. Over 30 assisted-living and skilled-nursing facilities in the Miami area were involved in fraudulent practices that included bribes, kickbacks, medically unnecessary and potentially harmful services.
In another example of Medicare fraud, a Houston nurse submitted claims and falsified health records for services that were never actually provided and, in some cases, were unnecessary. The fraud took place over a three-year period and amounted to $8 million in fraud.
What to Look For
For workers in healthcare facilities, you should be on the lookout for billing of services that never occurred, were obviously unnecessary to patients or that cost much less than the service billed for. In some cases of fraud, these practices occur at the top of an organization, like they did in Miami. In the case of the Houston nurse, it was largely the work of an individual who defrauded Medicare. This means that you could witness fraud on an institutional level involving the owners and operators of your workplace, or it could be the wrongdoing of an individual co-worker.
One of the biggest keys to identifying fraud in your workplace is the repetition and consistency in improper billing practices. In any workplace, a mistake can be made, or inefficiencies can lead to improper billing. However, if you notice a pattern of billing for unnecessary, unneeded or nonexistent services, you might be witnessing intentional deception and abuse of the system.
Coming Forward About Fraud
The Office of the Inspector General has resources and avenues for reporting Medicare fraud. Unfortunately, they receive such a high number of reports and tips from beneficiaries and providers that they are unable to respond to submissions. In other words, it can be difficult to know whether the information you’ve provided has made a significant impact.
For those who can gather enough evidence about fraud they’ve witnessed in their workplace, there are options to come forward as whistleblower. The False Claims Act can provide whistleblowers with an avenue to provide the Justice Department authentic and ample evidence that warrants intervention from the government. It is in these cases that those who report fraud will receive a portion of the recovered amount. If you choose to become a whistleblower, there are attorneys that focus on filing whistleblower claims who can help you prepare documents and submit information that will be more likely to garner the attention of the Justice Department.
Stopping Medicare Fraud is About More Than Dollars and Cents
It is true that Medicare fraud costs the government obscene amounts of money every single year, but the ramifications of Medicare fraud go well beyond the financial costs. By stopping fraudulent practices in our healthcare system, we improve the care provided by the system. We eliminate unwanted and unneeded services and prescribed drugs, many of which actually cause great harm to patients, many of whom are the sickest and most vulnerable patients in our country.
Intentional Medicare fraud involves much more than overbilling: it often involves deliberate administration of destructive medical care to the elderly and those who cannot take care of themselves. Medicare is designed to provide care for patients who need it the most, and fraud threatens to derail the intentions of the program.
If you believe that you have witnessed Medicare fraud in your facility, there are plenty of options that you have in front of you to report that fraud. Doing so will ensure the betterment of both your patients and the care provided by your workplace.
Bert Louthian is a whistleblower attorney in South Carolina who focuses on helping those who have been wronged, or who have witnessed wrongdoing to come forward to report fraud. He can be reached by calling or visiting his website.